Nursing Process: A Systematic Approach to Patient Care

1. WELCOME Nursing process approachUNIT-VIIPresented byMrs.BENAZEERAYNC

2. LEARNING OBJECTIVES 1. Describe the health assessment in context with patient/clients 2.Identification of illness problems, health behaviors and signs and symptoms of the client 3.Discuss the methods of collection ,analysis and utilization of data relevant to nursing process 4. Discuss the Formulation of nursing care plan ,health goal, implementation, modification and evaluation of care

3. Definition Nursing Process is an orderly, systemic manner of determining the client’s problem, making plans to solve them, initiating the plan or assigning others to implement it and evaluating the extent to which the plan was effective in resolving the identified problem. [Yura and Walsh]

4. Nursing process According to American Nurses Association,2003- The Nursing process is a systematic five step clinical decision making approach that Includes assessment ,diagnosis ,planning, implementation and evaluation. The purpose of the process is to diagnose and treat human responses to actual or potential health problems.

5. RELATIONSHIP AMONG THE STEPS OF THE NURSING PROCESS • Cyclic Process. • Each step is overlapping the other step. • Each step of nursing process is dependent upon the accuracy of the proceeding step (interdependent).

6. Steps are overlapping which means that you may have to move quicker for some problems than for others. • Evaluation involves examining all the previous steps especially focuses upon the goal achievement. (is the diagnosis accurate? Goal appropriate?)

7. COMPONENTS OF NURSING PROCESS

8. Characteristics of the Nursing Process • Within the legal scope of nursing • Based on knowledge-requiring critical thinking • Planned-organized and systematic • Client-centered • Goal-directed • Prioritized • Dynamic • Interdependent

9. Why should we use nursing process? (Benefits) • Delivers nursing care in a systematic or organized manner. • Nursing process is holistic in focus • Encourages identification and utilization of client strengths. • Promotes flexibility, independent thinking for nurses.

10. Why should we use nursing process? (Benefits) • Documentation enhances communication, continuity of care, reduces omissions and duplication of care. • Helps the nurses to have the satisfaction of getting the results.

11. Phases of Nursing process • Assessment: Collecting subjective and objectives • Diagnosis: Analysis subjective and objective data to make nursing diagnosis • Planning: Determining outcome criteria and developing a plan • Implementation: Carrying out a plan • Evaluation: out come criteria met or not

12. 1.ASSESSMENT Assessment commonly refers to in nursing, assessment is the“ systematic collection of subjective and objective data with the goal of making a clinical nursing judgment about an individual, family or community”.

13. Purposes To establish baseline data To determine client’s normal function To determine client’s risk for dysfunction To determine the clients strengths To provide data for the diagnosis phase

14. TYPES OF NURSING ASSESSMENT • INITIAL ASSESSMENT • FOCUS ASSESSMENT • TIME LAPSED ASSESSMENT • EMERGENCY ASSESSMENT • DATA BASE ASSESSMENT

17. TYPES OF NURSING ASSESSMENT Data base assessment • Performed on initial contact • Gather information about all aspects of clients health status • Identifies clients strengths and problems • It is planned, systematic, comprehensiveto ensure that all pertinent information is obtained.

18. This method of data collection uses an assessment tool which is not disease oriented, but holistic or human response oriented. • Developed according to nursing model • To know how the person functions as a biopsychosocial human being(holistc nursing focus) • Tells how patient lives his or her daily life (crucial when identifying the nursing diagnosis)

19. Phases of assessment I. Collecting data II. Validating the data III. Organizing the data IV. Interpretation of data V. Documentation and recording

20. Phases of assessment collecting the data: gathering information about the patient 3 phases of data collection: • Gather information before you actually see the patient. • Interviewing, examining or observing the patient. (physical examination) • Reviewing the resources (records and literatures)

21. Phases of assessment Types of data: • Subjective • Objective • Subjective and objective data that identify in a client as cues

22. ACTIVITY ………… FRAME Example????????????????

23. Sources of data Primary source: Client / Patient Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers, relevant literature.

24. Phases of assessment Methods of data collection • Interview • Planned, purposeful • Essential skill • Observation • Examination: physical examination, techniques, interpretation of laboratory results.

25. Assessment sequences • Cephalo caudal approach • Body system approach-examine all the body system • Review of system approach :examine only particular area affected

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38. Phases of assessment ii)Validating the data: Act of “double-checking” • To confirm accurate and complete • To verification …………….reliable and accurate

39. Validation helps you to • Avoid missing pertinent information • Misunderstanding situations • Jumping to conclusions or focusing in wrong direction

40. Steps of validation of data • Deciding whether the data require validation • Determining ways to validate • Identifying areas where data are missing

41. Purposes of data validation • Ensure that data collection is complete • Ensure that objective and subjective data agree • Obtain additional data that may have been overlooked. • Avoid jumping to conclusions • Differentiate cues and inferences.

42. Data requiring validation • Not every piece of data you collect must verified Examples :Reaptation of tem,pulse

43. Condition that require data to be rechecked and validated • Discrepancies or gap b/w the subjective and objective data Eg: cancer • Discrepancies or gap b/w one time and another time Eg:surgery-------interview yes • Finding those are very abnormal and inconsistent with other finding Eg: client temp-104 f but comfortable

44. Methods of Validation • Repeat the assessment-------different instruments • Clarify with additional question………by looking behaviour and signal • Verify the data with another health care professional • Compare your objective data with subjective data

45. iii)Organizing or clustering the data • Clustering the data into categories of information • Many institutions recommend a tool for organizing data. Eg) • Maslow’s Basic need • Body system model • Gordan’s Functional Health patterns gives methods of organizing the data.

46. Maslow’s Basic need

49. IV.Communicate/record/document data • Record • Factual manner • Record subjective data in client’s word

50. Purposes of documentation • Client assessment data outline • Ensures client and family -----vehicle of communication • Screening and validation • Help to diagnosis • Determine educational needs of client ,family and others • Determine eligibility of care